Dr vijay pal singh

M.S(gen.surgery)

Anatomy
Breast is a mature modified sweat gland
Paired mammary gland develop along with

milk line from axilla to inguinal region

1% Female having polymastia &

polythelia
Minimum postnatal development in
males & maximum in females upto age
of 20 yr & atrophy begin pre menopause
~40 yr
Breast extends superiorly from second
rib to inferior mammary fold medially
lateral border of sternum lateraly
ant.axillary line or mid axillary line
Amastia & athelia are rare

Located in superficial fascia of

anterior chest wall

~15-20 lobes of tuboalveolar
glandular tissue,fibrous connective
tissue & adipose tissues
Between deep layer of superficial
fascia & deep investing fascia of
pectoralis major is retromammory
bursa

Septa extends from deep layer of

superficial fascia to skin are coopers

ligaments
Most glandular tissues are found in
upper outer quadrant
Tail of spence extend towards axilla

Arterial supply
Internal mammary
Lateral thoracic
Intercostal
Thoracoacromial

Venous drainage
Lateral thoracic
Internal mammary
Axillary
Posterior intercotal veins directly

communicating with vertebral plexus of veins

(boston) that surround vertebra from skull to
sacrum

Nerve supply
Medial pectoral
Lateral pectoral
Long thoracic
Cutaneous

Lymphatic drainage
Pectoral (anterior) nodes
Subscapular (posterior) nodes
Humerial (lateral) nodes
Central
Apical
Interpectoral (rotter`s) nodes
Parasternal

Aetiology
Most common cause of death in middle

age women
Geography
Gender
Age
Genetics
Diet
Endocrine
Previous breast biopsy
Personnel history of breast carcinoma
Previous chest wall irradation

Oncogenesis
ERB B2
Hras
Myc
WNT2
Growth factors,
TGF alpha
IGF
ER

Pathology
Breast carcinoma arise from epithelium

of duct system from nipple end of

major lactiferous to terminal duct
Well differentiated
Moderately differentiated
Poorly differentiated
Depends on nuclear pleomorphism &
mitotic rate

Spread
Local
Lymphatic
Haematogenous

Clinical presentation
Lump
Indrawing of nipple
Peaud`s orange skin
Ulceration
Fixation to chest wall
Sign & symptoms of metastasis

Diagnosis
History
Clinical examination
Mammography
MRI
FNAC
Core needle biopsy
Incisional biopsy
Excisional biopsy
Punch biopsy
PET scanning

Sentinel lymph node

bopsy

Classification
DCIS-Comedo

-Noncomedo
Infitrating ductal carcinoma
Medullary carcinoma
Infiltrating lobular carcinoma
Tubular
Mucinus carcinoma
Inflammatory carcinoma

Stagging
0
I
IIA
IIB
IIIA
IIIB
IIIC
IV

Tis
T1
T2
T1
T3
T2
T3
T4
any T
any T

no palpable mass
<2 cm
2-5 cm
<2 cm
>5 cm
2-5 cm
>5 cm
chest wall,skin

no
no
no
n1
no
n1
n2
n2
n3
any n

mo
mo
mo
mo
mo
mo
mo
mo
mo
mI

Treatment
Wide local excision and primary radiotherapy
Partial mastectomy
Segmentectomy
Lumpectomy
Quadrantectomy
QUART
Removing 10 nodes-future recurrence

-stagging
4500 rads to whole breast

MRM V/S BCT

BREAST CONSERVING THERAPY

(BCT)
Breast cancer
screening programs

Increase mass
awareness

BREAST
CONSERVING
SURGERY

Patients with earlier

stages presenting
to clinic

Better Quality
of life

Better psycho-social
Adjustment

Modified radical
mastectomy
Mastectomy
Axillary lymphnodes dissection level 1 or 2

boundaries of ALND are serratus anterior

medially,axillary vein superiorly,subscapularis
musle plus thoracodorsal and long thoracic
nerve posteriorly and axillary fat laterally

Anatomic complication of
MRM
Vascular injury-1 &2 perforating vessels
st

nd

-axillary vein
Nerve injury -intercostobrachial nervenumbness of the medial aspect of arm
Long thoracic nerve-winged scapula
Medial & lateral thoracic nerve-pectoralis
muscle atrophy
Thoracodorsal nerve-internal rotation &
abduction
of shoulder are weakened

Locally advanced tumour

Neo adjuvant endocrine therapy
Anastrazole and exemestane
Those tumour expressed only low level of

estrogen receptor and over expressed the

growth factor receptors HER1 & or HER2
which are usually associated with a worse
prognosis,had a significant greater chance of
responding to letrozole than tamoxifen

Metastatic breast cancer

Surgery-metastatic lesion is solitary or

multiple lesion at single organ site

Surgery combine with adjuvant therapy
results are better
Radiotherapy -800 to 1000 rads (single dose)
to 3000 (10 fractions) for bony metstasis
Phosphorus32 and strontium89 are selectively
taken by involved bone

Hormonal

Aromtase inhibitors-anastrozole & letrozole

Fluvestrant anti estrogen has been approved
in tamoxifen resistant postmenopausal
metastatic breast cancer
In premenopausal
tamoxifen with or without oophorectomy or
LHRH-a like goserelin & resistant to both
should treated with megestrol acetate

Chemotherapy
Doxorubicin
Paclitaxel
Docitaxel
Capecitabine
Gemcitabine
Biological therapy
Trastuzumab-humanized mouse monoclonal
antibody against HER-2 protein
Biophosphonates-zolendronic acid decreasing
pathological fracures,pain & hypercalcimia

Chemotherapy
Primary therapy
CAF
AC

CMFP
Doxorubicin plus paclitaxel
Secondary therapy
Paclitaxel
Docetaxel
Vinorelbine
Capecitabine

Docetaxel
Trastuzumab
Carboplatin
Hormone therapy
Tamoxifen
Anastrozole
Fulvestrant
Megestol
Aminoglutethimide

ADJUVANT
RADIOTHERAPY
Indications of Radiation therapy

Patients with 4 or more positive lymph

nodes

Presence of extracapsular extension,

positive or close margins

T3 tumors with positive lymph nodes,

medial quadrant tumors

Any T4 tumors and pectoral fascia

involvement

RECENT ADVANCES IN
RADIOTHERAPY
CT simulators and Portal imaging

3DCRT

IMRT

IGRT

Portable LA for IORT

HOW TO DEVELOP CANCER

TREATMENT SERVICES IN

DEVELOPING
COUNTRIES
National policy
- NCCP

Resource allocation/ Phased

development

Human resource development

Investments in diagnosis/ treatment

Comprehensive basic services

Team approach

National guidelines of Rx

THANKS